Basic Information
| Provider Information | |||||||||
| NPI: | 1831119403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADA | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255849 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168546975 | ||||||||
| FaxNumber: | 9168546864 | ||||||||
| Practice Location | |||||||||
| Address1: | 4053 LONE TREE WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945316200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257563400 | ||||||||
| FaxNumber: | 9257541869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 11/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | G54251 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00G542510 | 05 | CA | MEDICAID |